History-taking
CPSA · Focused history · Cardiovascular
Palpitations
Characterise the awareness of the heartbeat and screen for a dangerous arrhythmia. The pattern (regular/irregular, fast/slow) and associated syncope guide urgency.
Focused questions
Characterise
- Ask them to tap out the rhythm — regular or irregular? fast or slow?
- Onset/offset (sudden vs gradual), duration, frequency, triggers (caffeine, alcohol, exertion, stress)
Associated / red flags
- Syncope or pre-syncope, chest pain, breathlessness (suggest a significant arrhythmia)
- Family history of sudden cardiac death
Causes to screen
- Thyrotoxicosis (heat intolerance, weight loss, tremor), anaemia, anxiety, drugs (salbutamol, stimulants), alcohol, caffeine
Differentials to screen
Atrial fibrillationIrregularly irregular, older/structural heart disease
SVTSudden-onset regular fast palpitations, terminates abruptly
Ventricular tachycardiaStructural heart disease, syncope, chest pain — dangerous
Ectopics / sinus tachycardiaMissed-beat sensation or exertion/anxiety-related, benign
ThyrotoxicosisWeight loss, tremor, heat intolerance, sweating
Red flags — exclude these
- Palpitations with syncope (arrhythmia — risk of sudden death)
- Palpitations with chest pain/breathlessness
- Family history of sudden cardiac death
- Palpitations on exertion
OSCE tips
- Ask the patient to tap out the rhythm — regular vs irregular is the key discriminator.
- Palpitations + syncope = get an ECG and think dangerous arrhythmia.
- Screen for thyrotoxicosis in every palpitations history.